Question

Assignment 1: Discussion Question You are the hospital safety officer. A unit nurse has sent an incident report to you about a patient fall. The patient, an 80-year-old man recovering from pneumonia, fell and broke his hip while getting up to go to the restroom. As the safety officer you know that a broken hip often leads to death in the elderly. Falls are a preventable cause of patient death and can lead to a lawsuit against a hospital. You notify the hospital quality manager that according to your analysis 40 percent of the patient falls in the previous year occurred during the night shift. There are eight adult units and two pediatric units in the hospital. Incidents of patient falls in a pediatric unit are rare. However, patient falls in the adult units are more frequent. There are three eight-hour shifts in 24 hours. Last year, there were 80 falls. It is June, and already this calendar year there have been 44 falls. You are concerned about the potential for a patient death, the potential for a lawsuit, and the hospital accreditation status. Which of the core quality management tools will you use to analyze the problem? Explain why you would use the tools you chose. Is there other data you want as you work on this problem? Why do you require other data?

Assignment 1: Discussion Question You the hospital safety officer. A

Assignment 1: Discussion Question You are the hospital safety officer. A unit nurse has sent an incident report to you about a patient fall. The patient, an 80-year-old man recovering from pneumonia, fell and broke his hip while getting up to go to the restroom. As the safety officer you know that a broken hip often leads to death in the elderly. Falls are a preventable cause of patient death and can lead to a lawsuit against a hospital. You notify the hospital quality manager that according to your analysis 40 percent of the patient falls in the previous year occurred during the night shift. There are eight adult units and two pediatric units in the hospital. Incidents of patient falls in a pediatric unit are rare. However, patient falls in the adult units are more frequent. There are three eight-hour shifts in 24 hours. Last year, there were 80 falls. It is June, and already this calendar year there have been 44 falls. You are concerned about the potential for a patient death, the potential for a lawsuit, and the hospital accreditation status. Which of the core quality management tools will you use to analyze the problem? Explain why you would use the tools you chose. Is there other data you want as you work on this problem? Why do you require other data?

Solution

In the case, the most considerable event is the increase in "the potential for a patient death" because all other concerns are caused by the patient death. If we able to analysis and control the potential for a patient death, the other concerns goes away.

The Core quality management tool which will be very useful to analyse the problem is "Cause and Effect" where we Identifies many possible causes for an effect or problem and sorts ideas into useful categories. Finally reach out to the final reason of the problem which will help us to eliminate the problem. There is some cause which is making the patients fall and die. We will analyse all the possible causes which is giving that kind of effect. If the final reached out cause / reason is being controlled, the problem will be solved.

The other data which is required is that during night shift, the quantum of the guards and what is the probability that they are performing their duties properly. This data is required to access the cause why cases are happening at the night shift only.